Big thanks to Vonda Wright and Chris Keating for putting together this session and as Vonda pointed out to me earlier this morning, and it rung a bell for me, we are all actually aging athletes, so this session is perhaps the most relevant session to all of us personally of the whole meeting. And I also appreciate including hip in this session, as you know the knee bone is connected to the hip bone, and they do interact very much. So I'll talk mostly about hip preservation, which is our focus, and specifically hip preservation in the aging athlete, which has been an area of research and innovation at our center. My disclosures are with the AOS. So it's already been said, but life expectancy has increased significantly, adults continue to be increasing their levels of activity, and hopefully that trend will continue and continue to see people stay active for a long time. Now before we dig into hip preservation, we have to acknowledge that the total hip replacement has been acknowledged by the Lancet as the operation of the century. It is a great operation. So any time we're talking about hip preservation in the older population, we sort of have to ask why not do a hip replacement, or when should we do a hip replacement. So why not do a hip replacement? First of all, hip pain does not equal osteoarthritis. A hip arthroscopy may have a risk of major complications, less than 1%. A hip replacement may be 10 times that or 20 times that. And obviously a revision hip replacement can be much more than that. So bigger operation equals bigger risks. So if we can accomplish relief of pain with a less invasive operation that has much smaller risks, that has a benefit. There's an arthroscopy, there's a replacement, and this is when replacements go wrong. Now when we do replacements, some of our work at American Hip Institute has been focused on making a good operation even greater. And part of that has been with robotic surgery, which we have shown can increase the accuracy. I'll show you a publication to back up each of these assertations. It increases bone preservation. We actually are able to prepare the bone more accurately and therefore preserve more bone. It improves the clinical outcomes and decreases the risk of complications like leg length discrepancies or dislocations, largely due to the accuracy. So we can make a great operation even greater with advanced technology and refinements to our technique. The ultimate goal is making the hip feel like a normal hip. And that means restoring normal muscle tension and vectors around the hip to make it feel so. That's dependent on the restoration of the spatial relationship between the femur and pelvis. And that's where patient-specific three-dimensional planning and execution comes into play in three dimensions. With this approach and with this technology, we achieve significantly higher Harris hip scores and forgotten joint scores compared to manual hip replacements. And patients with robotic replacements were more than twice as likely to feel like they had a normal hip, which is ultimately our goal. So this is what some of our aging athletes may look like. Bob hit a milestone, walked 12,000 miles since his new hip, and Karen was back at a gym six weeks to the day taking her favorite spin and yoga classes. So these are our patients. These are who we're talking about. Now hip preservation then is competing with a good operation, perhaps a great operation in the hip replacement, but it's a less invasive option and it can have much lower risks of significant complications. So hip preservation surgery has widened our options in the older patients. So how beneficial is it actually for our patient? Here's another strike against us. We know that age is a significant negative predictor or prognosticator for just about every surgery, but specifically for hip arthroscopy. So we know that a 20-year-old does better than a 60-year-old. And that's, again, probably true of most operations. This was the largest study that had been done at the time in over 1,000 patients with five-year outcomes of hip arthroscopy, where we did a multivariate regression analysis to understand these various predictors. And you can see that age is a negative predictor here in the slope of these curves. As you get further out on the age curve, you have a diminishing prognosis. So how do we get around that? A few ways. First, a big area of our work right now is in predictive analytics. This means using big data algorithms to infer relationships that are not otherwise readily understood. This means analyzing amounts of data not possible with other statistical methods and then using experimental or machine learning to continuously improve models as new data is added. And ultimately, this gets us where we can predict an individual patient's outcomes based on big data sets and use those predictions to set expectations and set the stage for informed shared decision-making. So this is what this looks like. We'll input the demographics and disease-specific variables of the specific patient. Those variables are compared to patient-specific information from thousands of other patients, and then it calculates patient-specific prognosis. So this will be for a specific patient. And you can see at the top here, this is really the melding of evidence-based medicine, artificial intelligence, and individual patient data. You take these three and combine them together to create patient-specific predictive analytics. So this will give us a predicted success rate. It'll give us what looks like a Kaplan-Meier survivorship curve, but this is predicting the future Kaplan-Meier survivorship curve for this patient. In other words, their probability of survivorship of their hip over time is reflected in this purple curve here. And their probability of needing future surgery over time is reflected here. So you can use these curves to predict at any given time, whether it's a year or 10 years, what is their likelihood of needing subsequent interventions. So that's predictive analytics. The second aspect of how we approach this aging athlete population is consideration of sport modification. And Vanda said earlier, very rightly, I think telling people stop doing it just isn't the right move. We want people to stay active. But that doesn't mean we can't modify. We can individualize in each case and take into consideration the patient's needs and goals to keep them active and counsel them on the best realistic and viable scenario. And we can use the predictive analytics to do this, to inform this conversation. And then the last major piece is we've developed operations that are actually different in the older population than in the younger population. Operations that are better suited to the pathology that they have in many cases. So when we have a torn labrum and a simple repairable torn labrum, we repair the labrum. On the other hand, when we have a segmental defect with a preserved chondrolabral junction, we can perform a segmental augmentation with a graft. If we have a segmental defect with a compromised chondrolabral junction, we can perform a segmental reconstruction. And if the labrum's irreparable altogether and we have complete circumferential degeneration of the labrum, we can reconstruct the whole thing. So since this was sort of a knee session, I'll draw an analogy to an ACL repair. You are probably not going to do an ACL repair in the patient over 50. You're probably going to do an ACL reconstruction. And there is some comparison there to the aging athlete in the hip. We may be more likely to do a reconstruction of a diseased labrum in an older patient. And this has given us a whole new avenue of treatment of pathologies, which has been wildly successful in the older patients. So I'll mention three specific studies on the outcomes at American Hip Institute in this population. We've done a lot of work on outcomes and there are a lot more, but I'll mention three. So the first showed that patients 50 or older showed similar improvements to patients age 30 or younger in PROs and satisfaction scores. Now their survivorship was lower. There were more conversion to replacements, but there were actually fewer revision arthroscopies in the older group. And overall, the functional improvements were comparable to a younger group, keeping in mind that we're tailoring the surgery to the age and to the pathology in the older patients. So we may not be doing the exact same procedure in a 60-year-old as we're doing in a 20-year-old. It's tailored to that patient. The second study showed that patients age 50 or older demonstrate statistically significant improvements in their PRO at midterm follow-up, at five-year follow-up. So we start to track this over a longer term. And this is important to follow. We're now working on our 10-year outcomes in this group. And lastly, extending this even further out on the age curve, patients over 65. Patients over 65 with labral pathology who have failed non-operative measures still can obtain modest improvement from hip arthroscopy, and what we're seeing now is this is getting even better with the advent of circumferential labral reconstruction, which gives us an option to biologically rejuvenate an older patient's joint. The last point I'll mention is sort of something in between hip preservation and hip arthroplasty, which is resurfacing, which plays a very important role in select patients in our aging athlete population. So this is Andy Murray after his hip resurfacing, and this is Andy Murray later after his hip resurfacing, which I think has brought a lot of positive attention to the procedure as a very good procedure, particularly for the middle-aged athlete. So resurfacing versus replacement. When the technique is mastered, resurfacing can achieve superior function and durability in athletics, a dislocation rate approaching zero, and we've developed an anterior approach for the Birmingham hip resurfacing, which allows it to be done through an entirely muscle-sparing approach. So this is a resurfacing versus a replacement. This is Peter Walters, he's actually a 61-year-old, now squatting 300 and something pounds after bilateral hip resurfacings. So again, this is our patient. This is obviously a very athletic guy, he's been lifting weights his whole life. He's a professor at one of the colleges in Chicago, a professor of physiology, and he's really into this, and he's continued to do it. So this is our patient, he wants to stay active, we can come up with solutions to keep him active. So to conclude, we all agree aging athletes deserve our attention, and they deserve individualized treatment. Hip preservation can succeed in this population, and we can optimize its chances of success using the combination of predictive analytics, patient-specific counseling, and advanced restorative procedures. And for the patient who is too arthritic for hip preservation, we need to have options for them too. And those options may be a high-performance replacement with robotics and a patient-specific plan, or Birmingham hip resurfacing, ideally through an anterior approach. So thank you very much. Thanks for the invitation.

hip preservation

aging athletes

predictive analytics

surgical options

individualized treatment